Primary Peritoneal Cancer 101

00:00:00:00 – 00:00:42:13
Unknown
Hello and welcome to the primary peritoneal cancer, 101 recording. I’m Maggie Nicholas Alexander, the Senior Director of Gynecologic Cancer Patient Support and Education at SHARE. For more information about upcoming webinars, support groups, our helplines and more, please visit our website at sharecancersupport.org Today we’re speaking with Dr. Dellinger. Before we began, I’d like to hand it over to Dr. Dellinger to introduce herself.

00:00:42:15 – 00:01:10:07
Unknown
Okay. Hi, this is Tom Dellinger. I’m a G. Man, oncologist and associate professor at the Division of Juvenile Ecology at City of Hope in Duarte in California. I’ve been doing this for the past 12 years, and my expertise specifically is and peritoneal cancers. And I am an expert in hepatic and pipe and other novel intracranial therapies. Right. We’re so happy to have you here today, right?

00:01:10:08 – 00:01:42:00
Unknown
Yes, I’m happy to be here as well. So I hope that you can all see my screen. So I will be talking today about primary peritoneal cancer. So let’s see here. Okay, good. So what’s I’ll be talking about the differences between primary anal cancer and ovarian cancer, the risk factors and causes of this cancer, how they present, what the treatment is and what is the latest in the research for primary cancer.

00:01:42:02 – 00:02:09:17
Unknown
So let’s first start defining what is the peritoneum. It is not a well-known organ to most people and even physicians. So the peritoneum is a layer that covers all of the organs within the abdomen, your tummy, as well as almost like an inner skin that covers the inner lining, the inner lining of the abdomen and the organs such as the ball, the intestines, the liver and other organs.

00:02:09:18 – 00:02:34:20
Unknown
So the parietal peritoneum is the lining, the parts of the covers, the inside of the abdomen, kind of like an inner skin. And the visceral peritoneum is the layer that covers the organs, including the uterus, the liver, the intestines. There’s a little bit of fluid that usually is in between these layers, which in the intraperitoneal cavity, and that is normal.

00:02:34:20 – 00:03:05:03
Unknown
That’s just helping with kind of the separation of these these layers. Now, primary peritoneal cancer is a pretty rare cancer. And we think that the primary critical cancer arises from the inner lining, the peritoneum of the abdomen. But there’s other peritoneal cancers as well, which are not primarily they arise from GI cancers, colorectal gastric, and those are essentially non primary cancers.

00:03:05:03 – 00:03:33:02
Unknown
That primary peritoneal cancer is really a rare cancer that arises from the peritoneum, not the ovary, but behaves very similar to the ovarian cancers. And we think that that is because in embryogenesis. So when, when an embryo forms and the organs form within an embryo that the primordial cells that come that become the ovary and the peritoneum they derive from the same primordial cells.

00:03:33:04 – 00:04:01:02
Unknown
So we think that they are. So the two cell cell phones have very little similarities. And therefore our primary peritoneal cancer behaves very similar to ovarian cancer and tubal cancer. But really the two cancers, primary peritoneal cancer and ovarian cancer are treated in the same way they present maybe in slightly different ways, though pretty similarly. But the treatment and the prognosis is the same.

00:04:01:02 – 00:04:25:11
Unknown
So when your doctor might be talking to you about ovarian cancer, but you have primary kidney cancer, the two really are interchangeable when it comes to treatments. So primary peritoneal cancer is a rare cancer that affects women in the U.S. It only affects about 10% of all women who have ovarian or fallopian tubes, cancers. We don’t really know the causes of primary anal cancer.

00:04:25:11 – 00:04:58:07
Unknown
It’s likely multifactorial, meaning that it’s caused by many different reasons. Most primary peritoneal cancer patients do not have the BRCA one or two gene, which affects about 15 to 20% of ovarian cancer. It’s an inherited gene that gives you an increased risk for breast and ovarian cancer. Another difference between ovarian and primary peritoneal cancer is that primary peritoneal cancer does not present in stage one or stage two.

00:04:58:07 – 00:05:22:24
Unknown
It only presents as a stage three or stage four and stage three, for example. It mostly affects the omentum, which is the fat apron that hangs from the colon in the stomach and protects the abdomen. But that is a main area location for primary cancer to occur. But the cell type that affects ovarian cancer is the same this as what we see for penetrating cancer.

00:05:22:24 – 00:05:57:05
Unknown
The most common one is hydrate series psoriasis, the cell type that we see in this cancer. So how do primary skin cancers present? Well, they really present the same way as ovarian cancers. And unfortunately, these are very vague symptoms. They tend to be very vague abdominal and GI symptoms. And the most common symptoms we see are abdominal bloating, abdominal fullness, abdominal pain, or potentially the desire or the need to go to the bathroom more frequently to to pee more frequently.

00:05:57:07 – 00:06:25:13
Unknown
But it’s the very vague symptoms often misdiagnosed by primary care physicians. And because it’s it’s it’s really a symptoms that could occur in many other GI disorder. And so it’s it’s difficult to diagnosis. So what are the tests to diagnose? Well, the first thing oftentimes that a patient will obtain is go to the primary care physician and have an abdominal and pelvic exam.

00:06:25:19 – 00:06:51:15
Unknown
And the abdominal exam will really mean pushing on your abdomen, seeing that you have insides, which is fluid, that fills the abdomen and doing a pelvic exam. So essentially a vaginal exam to see whether there’s any palpate for any pelvic masses or bearing masses and then the blood tests. So the tumor marker that we use in ovarian cancer is called C 125.

00:06:51:17 – 00:07:27:17
Unknown
This is a blood test that is used for bearing cancer and is also used for chronic kidney cancer and is usually elevated when you have primary cut, not cancer, but C 125 level is not a incredibly diagnostic marker. We use it to manage ovarian cancer and primary peritoneal cancer, but unfortunately the test is more of a marker of inflammation and so therefore it can be elevated in other types of non-cancer conditions, such as any new treehouses or fibroids, which are all benign conditions that can cause irregular menses and pelvic pain.

00:07:27:19 – 00:07:58:01
Unknown
Pregnancy can cause an elevated C 125 cycle of an inflammatory disease. So there’s a number of different benign conditions that can cause a mild or even moderate elevation. So in so we frequently rely on imaging studies to diagnose ovarian and primary cancer. The most common tests use of a public ultrasound. So this is an ultrasound that uses sound waves to build a picture.

00:07:58:03 – 00:08:33:22
Unknown
Frequently, it’s an individual so intravitreal as well as an abdominal ultrasound to look for ovarian masses. And then the most common and really the most definitive definitive test is a C t scan that includes from the neck down to the pelvis, a chest, abdomen, pelvis, or alternatively an MRI of the abdomen, pelvis to take a look whether there is masses, pelvic masses or varying masses in the abdomen, whether there’s any other spread of cancer, that there’s any fluid such as a sidings or seizure.

00:08:33:24 – 00:09:08:16
Unknown
So the stages for primary peritoneal cancers, as I mentioned, are similar to bearing cancer, except there’s no early stage, There’s no stage one stage two, all primary peroneal cancer automatically at a stage three or stage four. So the most common area of presentation. So usually in the medicine momentum is the Saturday that I mentioned earlier or somewhere in the peritoneal area, whether it’s on top of the colon, the intestine, whether it’s in the pelvis, in the middle layer, that’s usually where we see no cancer.

00:09:08:18 – 00:09:38:04
Unknown
And so when it’s within the abdomen, it’s considered stage three. Once it has spread beyond the abdomen, such as, for example, into the lungs and the chest with fluid or into lymph nodes in the neck, then it’s considered a stage for primary. So the treatment for primary technical cancer is really the same as for ovarian cancer, and it depends on a number of different condition.

00:09:38:04 – 00:10:05:14
Unknown
But the combination is usually surgery and chemotherapy. And what all of that is done depends on whether the cancer spread outside the abdomen. So, for example, whether you have any lesions in the lungs, fluid and along or lesions in the lymph nodes in the neck, or whether every tumor is still contained within the abdomen, within the belly. And also your general health is being considered.

00:10:05:14 – 00:10:30:08
Unknown
And whether you can tolerate a surgery up front. So the usually the best method is to do a surgery first to remove all of the cancer, every single millimeter of tumor inside the abdomen and then follow up with chemotherapy. Now, if that is not possible, either cancer spread outside of the abdomen or in general, health is good enough to tolerate a big surgery.

00:10:30:14 – 00:10:53:24
Unknown
Then we give chemotherapy. First, we call that neoadjuvant chemo and then follow it up with surgery option. But the goal of the treatment for advanced ovarian and primary potential cancers relates to shrink the cancer and control it. The tumor for as long as possible. So we talked a little bit about surgery or any surgery in ovarian and primary.

00:10:53:24 – 00:11:18:12
Unknown
Peritoneal cancer is typically referred to as the debulking surgery, which to many women and patients really sounds like a really ominous term. And in some ways it is it is a very big surgery for many, one, not all, but at a minimum, it involves a hysterectomy and removal of the ovaries unless one or the other have been removed in the past.

00:11:18:14 – 00:11:44:05
Unknown
And for most women, it is it is a big surgery. It is an up and down incision throughout the entire abdomen to expose every single corner of the abdomen. So we want to look behind the liver. We want to look all around the stomach, in the pelvis, on all of the intestines. So we really need a big area, a big incision to look at everything.

00:11:44:07 – 00:12:15:22
Unknown
And then we get to work and we remove every single millimeter of tumor when feasible. And that might involve removing what is seen here. The diaphragm. The diaphragm peritoneum is the layer that cut that is between the chest and the abdomen. And oftentimes tumor can occur in that area. It sometimes involves the colon or the small ball. And this picture specifically shows that the colon, this is the rectum actually, which sits right behind the ovaries.

00:12:15:24 – 00:12:37:13
Unknown
And oftentimes the tumor nodules and then requires cutting out that portion of the colon, just like as you see here, and then putting those portions together. So this portion with a portion would be below this area where the two lines are. Sometimes the small ball is involved and then the same cutting out of the tumor and reconnecting that occurs.

00:12:37:13 – 00:13:11:15
Unknown
So as you can see, this can be a quite extensive surgery. It’s a long surgery and it really has one singular goal, which is to remove every single millimeter of disease that we can do, we can see and safely do. Now, every primary peritoneal cancer patient will require chemotherapy. There’s really no way around it. And that is because even if we if we had a successful surgery, there are microscopic cells that are still around that need to be killed.

00:13:11:17 – 00:13:49:02
Unknown
And chemotherapy does a really great job. It kills all fast growing cells. And two lung cancer cells are possible in cells. The drugs are administered typically into the bloodstream and the chemotherapy is either given before surgery as part of neoadjuvant chemotherapy, as I had alluded to earlier, or it’s given after surgery as part of what we call A.S. In therapy, sometimes women are unable to undergo surgery due to the health conditions that preclude them from having a big surgery and in which case then they would have chemotherapy.

00:13:49:04 – 00:14:17:16
Unknown
Now, the most common drugs that we use in the first line setting for primary cancer are carboplatin and paclitaxel. And sometimes we add bevacizumab, which is an antibody drug. And so these are really the most common drugs we use for chemotherapy. And I mean for primary kidney cancer and ovarian cancer and various radiation is very rarely used for primary training or against involving in cancer.

00:14:17:18 – 00:14:49:24
Unknown
It typically is used for really more isolated diseases such as, let’s say, nodal disease near the periodic nodes that are infiltrated with tumor or potentially isolate liver tumors, which may respond with liver ablation. But typically radiation is not a common mainstay of treatment. And again, as I alluded a little bit to society, societies is fluid that occurs inside the abdomen.

00:14:49:24 – 00:15:22:08
Unknown
Many ovarian and primary kidney cancer patients present with the it’s fluid inside the belly that makes you quite bloated. And this oftentimes gets drained. We call that a person T cells in some women will need multiple person pieces before they can get chemo or surgery. But usually with the combination of chemotherapy and surgery this size, fluid dries up and the chemotherapy is able to effectively take care of that.

00:15:22:10 – 00:16:01:11
Unknown
Fluid can also build up in the chest. So full of fusions, as you can see on this chest, x ray can cause a partial white out of the chest x ray, and that can also be managed by removing that fluid from the lungs, the lung seals. And you can do that with a procedure called SAR synthesis, where a needle is being introduced in between the ribs in the back and the ultrasound guidance in order to drain the fluid that’s within the chest and then hopefully release the kind of shortness of breath, the breathing problems by the patient.

00:16:01:13 – 00:16:33:00
Unknown
So there’s a lot of research that has really come to the forefront for ovarian cancer. And in that sense, also primary cranial cancer, because those two are treated the same way. And I won’t go over all of that. Many, many advances occurred from PARP inhibitors for Bronco mutations and HRT to now folate receptor antibody drug conjugates, which all have really changed the lives of ovarian cancer patients.

00:16:33:02 – 00:17:11:15
Unknown
But my goal for this presentation was really to focus on peritoneal therapies. We know that primary cancers occur primarily in the medium in the abdomen, and therefore we’re primarily looking for novel intraperitoneal or regional therapies. And there’s one society in particular called the is STP or the international Society for the Study of Pleura and Peritoneum, which focuses on diseases and cancers off the peritoneum and the pleura, which is or is referring to diseases in the chest rather than in the abdomen.

00:17:11:21 – 00:17:42:18
Unknown
And this is a society that really promotes the these kinds of intracranial or regional therapies. So I’ll go over briefly what the latest research is for peritoneal cancers. So first, let’s talk about regional intraperitoneal, chemotherapy first. And really this leverages the fact that the peritoneal cavity or the abdominal cavity that I explained earlier today is really the principal site of disease in ovarian and primary cancer.

00:17:42:23 – 00:18:13:12
Unknown
So meaning most of the disease that we see in primary perinatal cancer is within the abdomen, either on the intestines or on the inner lining of the abdomen. So why not give chemotherapy directly inside the abdomen to touch those metastatic cancer nodules? And so in ovarian cancer, in primary panel cancer, this has been done by placing a cord and you can see the ports with a catheter that leads directly into the abdomen in order to deliver the chemotherapy directly into this abdomen.

00:18:13:14 – 00:18:47:15
Unknown
And this allows for more concentrated therapy to be delivered in, as well as for this chemotherapy to come into close contact with those tumor cells. And so this particular therapy in sorry about that, that already jumped ahead. This particular therapy has been demonstrated to have an overall survival benefit in ovarian cancer in primary peritoneal cancer. However, the side effects, unfortunately, really preclude a general uptake of this therapy in most communities in the US and the world.

00:18:47:15 – 00:19:22:06
Unknown
And so this has really gotten out of favor and we don’t routinely do intraperitoneal chemotherapy also because there’s other therapies now available. Now one regional therapy, intraperitoneal chemotherapy, which has become much more popular, is part of our routine armamentarium nowadays is heated chemotherapy or hyper hypothermic intraperitoneal. Chemotherapy is a treatment that we deliver at the time of surgical debulking and in fact, actually interval search for the for ovarian or prime kidney cancer.

00:19:22:08 – 00:19:49:14
Unknown
It requires a debulking surgery, meaning we have to clear all of the tumor that I’ve explained early in the big debulking surgery. And then we can place temporary catheters during surgery and give the key to chemotherapy through a pump, as you can see here, and then cycle it through the abdominal cavity in order to have the heated chemotherapy come in close contact to the tumors.

00:19:49:14 – 00:20:17:05
Unknown
That may still be the microscopic tumors that may still be remaining after the surgery. And the rationale for the heat is that it helps the chemotherapy work better because the chemotherapy actually can be a little more effective at slightly elevated temperatures, such as 42 degrees Celsius. And we also know some a winner from a randomized clinical trial in ovarian cancer.

00:20:17:11 – 00:20:42:23
Unknown
That high peg adds to the overall survival of ovarian cancer patients by about a year when given the time of the interval to bulk. And so we have a good rationale and we have clinical evidence that high tech works innovative sets. Now, intracranial chemotherapy has really undergone an evolution over the last several decades. We’ve gone from A.T.M. to now Hi pack.

00:20:43:02 – 00:21:10:00
Unknown
And now the question is, could we improve on this? And what is the evolution? What is the next generation to intraperitoneal chemotherapy? And so Pipette is a novel therapy that can be given also directly inside the belly. But this is given for patients in the recurrent setting, not in the first line setting. And it doesn’t require surgery, meaning it doesn’t require surgical debulking to remove all of the tumor.

00:21:10:02 – 00:21:44:24
Unknown
So the pipette is essentially chemotherapy that is given inside the abdomen as a spray to a device, which is a aerosolize or nebulizer. We do this at the time of the small surgery, the minor surgery where you only place two or three little ports, tiny little incisions like tubal insertions. And these kinds of surgeries are pretty routine. So most patients will understand these may be as laparoscopic surgery or surgery for, let’s say, removing a gallbladder or removing an appendix.

00:21:44:24 – 00:22:37:12
Unknown
Usually this that’s what laparoscopic surgery is used for, except that during our kind of laparoscopic surgery, we don’t do any removal or we don’t actually do any debulking surgery. It’s really only used. I apologize. It’s really only used for for delivering the chemotherapy. This aerosolize spray of chemotherapy. And the thought process of doing this as a spray is that the rationale is that the chemotherapy will disperse more evenly throughout the abdomen and to be able to reach every single little corner inside the belly and therefore reach all of the tumors, but also go deeper inside the tumor in terms of depths of tumor reach, because the pressure that we at the same time give inside

00:22:37:12 – 00:23:10:05
Unknown
the abdomen, which is routinely given for these kinds of surgeries, can also drive the pressure. I drive the chemotherapy, the drug deeper into the tissues in the tumors. So currently, pipework is used in an experimental setting in the US. In the U.S., we have a clinical trial at City of Hope. We use that for recurrent ovarian cancer. So as well as a number of GI cancers such as colorectal and stomach cancer, for whom surgery meaning debulking surgery is not an option.

00:23:10:07 – 00:23:42:19
Unknown
It’s been demonstrated to be very safe and we are essentially continuing for the clinical trials, determined that it’s efficacious, efficacious in the kind of ovarian cancer. So I just want to briefly talk demystify high peak versus hyper. I see a lot of patients would come to me and use those terms interchangeably and they’re really very different. And as I mentioned, high tech use of seeds, it’s it’s actually curative.

00:23:42:21 – 00:24:07:09
Unknown
We use it at a time of social called debulking, meaning a big debulking surgery to remove a tumor. It’s not repeatable, it’s only a single dose. And there are some toxicities such as kidney side effects. Whereas with 20 pack, we don’t do see, we use pressure, we use a nebulizer is considered currently a palliative therapy, meaning we use it to reduce symptoms from cancers.

00:24:07:11 – 00:24:32:18
Unknown
We don’t perform a search for the walking. We do repeat it. We repeat it at least three times, meaning you have the pipe back and then you repeat it 4 to 6 weeks later and you do that up to three times or more. And the toxicities are considered pretty low. We have enrolled a number of women and cancer patients in our trial.

00:24:32:18 – 00:24:59:07
Unknown
This is actually my patient ovary. Nuts. She underwent six cycles of pipe back and did really well. She had a great response and she was featured in this Cheer magazine, which is a patient oriented magazine where she described hepatic as a really well-tolerated therapy. She thought that the side effects were really better than what she saw with the intravenous traditional chemotherapy that she had.

00:24:59:07 – 00:25:33:21
Unknown
And so she really was a fan of this therapy, and it really worked well for her. She had a good response with progression of four to. So as I mentioned, we do have a trial at our institution. We’re actually the only U.S., I think trial. I’m the national PI for this trial. My copies of the role for the GI side of the trial and we have numerous collaborators, including at the Mayo Clinic, as far as I know as well, where we have a number of really great collaborators who also enroll patients onto this type of trial.

00:25:34:02 – 00:26:08:04
Unknown
And we enroll patients with ovarian uterine colon cancer up in the SEC as well as gastric cancers. So the takeaway points from this lecture are that primary peritoneal cancers where it’s really treated in the same way as ovarian cancer and the novel research from primary peritoneal cancer is really the same as Bulgarian cancer, with a difference that we also focus on peritoneal therapies such as type, act and other novel.

00:26:08:06 – 00:26:35:02
Unknown
And so I hope that this was an interesting lecture for you, and I’m happy to answer questions. Thanks. Thank you, Dr. Dellinger, for your informative presentation. We really appreciate you joining us today of course. My pleasure.